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Wednesday, June 17, 2009

Worried

I really, really don't like to post about political topics. Mostly because it is inflammatory, but also because, to me, it is extremely personal. However, based on recent media coverage, and President Obama's recent remarks to the AMA, I feel that I cannot keep silent on this subject. In his recent speech to the AMA, he downplayed the importance of tort reform in decreasing rising medical costs (such as unnecessary, expensive tests, ordered primarily to CYA and keep the lawyers at bay). More disturbing, however, was the notion that, in a "public option" (aka Government-run plan) he would base physician rating and reimbursement based on their personal health outcomes.

So, wait a minute, what's wrong with that? You ask. I mean, it is the doctor's *job* to make you *better,* right? It doesn't seem so horrible...you have a cold, you visit your physician, s/he diagnoses you with a viral infection, you get better, life goes on. But, what about this? As a physician, your patient population is obese. Despite your multiple attempts and counseling and lifestyle change recommendations, your patients continue along their unhealthy lifestyle, becoming even more obese. Guess what? You get a pay cut. Your patient that has smoked a pack a day for 50 years, and laughs in your face at your attempts to counsel smoking cessation develops COPD. Sorry, that is coming out of your hide. You did such a *bad* job of taking care of this patient! Your diabetic patient doesn't fill their medicine for a month, and then comes in to the hospital in frank DKA. *Your* fault for a negative outcome. Then, to add more fun, your ability to order laboratory/imaging tests will be limited (in the interest of keeping costs low), but if you miss out on a diagnosis? Your *fault,* and here come the lawyers for their piece of your livelihood. Where is the personal responsibility?

Who wants to put up with years of rigorous training, difficult study, and mountains of student loan debt only to be stymied in patient *care* at every turn? Surely not our best and brightest. I am worried about the future of our profession. A "public option" (not "free," by the way, more like $62,000 taxpayer dollars per person) for all intents and purposes will likely undercut any private competition (not to mention the tax burdens that will be levied to discourage competition). This will leave us, both patients and physicians, with only one choice. Government Medicine. Just like Government Motors. I don't want to become a government employee. I don't want my health care options to be limited to government employees. I don't even like to spend a day at the DMV!

I do believe that some reform, obviously, is needed, but I think it needs to be more geared to catastrophic coverage. I think we need to go back to fee-for-service health care, even schedule fees on a pro-rated percentage based on income to make health care visits affordable for all. Get rid of insurance for preventative care, labs, and office visits. Competition will then drive the costs down naturally. We, as physicians, can stop shuffling through piles of insurance paperwork and prior auths and get back to doing that which we were trained to do. Something that we love to do....take care of patients! Personally, I feel that "free" = "of little value." I believe we need to give people back a financial stake in their health care, and, perhaps, when they are financially vested in staying healthy, then they will value their health, and their health care providers, once again. Until then, I jump through a few more hoops to get my patients the care they need, and I worry about the future of our profession, and our nation.

28 comments:

amen to your post! seriously - I take care of a bunch of old farmers and adolescent pregnant women - most of what I say falls on deaf ears. Obama's speech worried me as well - ugh! Many of my patients already have a sense of entitlement and then when I don't fix them, I "pay"?? Certaintly not going to fix the problem of me not ordering a ct for abdominal pain. And, how do I change how I practice with ordering all those tests? Its hard to feel confident in your diagnostic abilities when your patient is the "consumer" and when lawyers are out there just waiting.

From the perspective of a teacher who works in a public school... I can't agree more. We are currently under a federal program No Child Left Behind that sounds good by it's title. But the reality is that our school is currently facing decreased funding because our special ed students are making adequate progress as determined by the federal government.

The political party that came up with this plan ran under the campaign of local government control. It doesn't make any sense to me.

I have to say that I never thought that regulating education was a good idea, but I never thought that it would happen, either. I can't imagine a plan that would work for our whole nation for education or healthcare. For both areas we have the best, the most motivated and the laziest, most deprived. How can we at providers (health or education) be paid based on how well our "clients" work.

This still comes back to a line my dad used to use on us as kids, "You can lead a horse to water, but you can't make it drink."

Another teacher here...and a doctor's wife. I can't agree with you more!

The idea that a patient can abuse their own body and ignore doctor's advise is bad enough...but when a doctor is then held accountable for it, it is ridiculous.

I read on AMA or NEJM (cannot remember which) that one of the reasons AMA is not being heard is because support coming from Doctors on the campaign front is about $189/per year per doctor vs over $5000 per year per lawyer. It is unfortunate that the bottom line in our political process is that those who rule will listen to those who pay them more, but that is the reality of it (this is what the article was basically saying). It also said that until doctors contribute more, it is likely we will not be heard.

Guess what? As soon as my husband is done with med training, I am jumping on that ban wagon...I'll contribute and be a voice in one of their ears. I just hope it makes a difference.

I agree with you as well. I am a first year medical student and a mother of 3. I am concerned for what this type of reform would mean for me when I graduate. I am incurring great amounts of debt to basically turn my life over to med school for the next 4 years. Is the government going to pay off my student loans when they make it impossible for me to pay it back? What about the reasons I got into this field to begin with--patient care? Will I have to practice defensive doctoring in order to avoid lawsuits? In addition, we are taught in our doctoring courses to not coerce our patients, but to fully inform them and let them have autonomy. How will I be able to do that, when I know their choices will have a great effect on my practice and ability to provide for my family?? This is very disturbing and I hope that the physicians with leverage and power in this country will speak out on our behalf and on the behalf of our patients' care.

I feel more and more as if I am living in a Lewis Carroll fantasy world, or participating in "Opposite Day" at a preschool.

Those who do not work or contribute anything to society are clamoring for more and more "free"...free health care, free housing, free personal care, free daycare. Meanwhile, those of us too damn dumb to hop on the disability and welfare dole are paying more and more taxes so we can go to work (every DAY!) and be abused in every sense of the word by these morons, while being lectured about how intolerant and ignorant we Americans are--by our own President.

Did everyone in government fail third grade math?? If working tax-paying citizens put four dollars in the kitty every week, and then get back their "share" of a single dollar after the kitty is shared five ways with non-contributers, how long is it until [a] the kitty is empty and [b] the taxpayer decides that if he gets a dollar every week ANYWAY, why not "earn" it from his couch like everyone else??

- it would not be fair to hold me accountable for the patient who makes the choice not to take the medications on a regular basis.

- I just worry that a catastrophic-based insurance philosophy would lead to many of my patients with chronic illnesses like diabetes and hypertension to go either under-diagnosed or unable to keep clinic appointments.

Re tort reform.... I mostly agree. Most lawsuits turn out to be frivolous. On the other hand, occasionally there is gross negligence that results in a person needing round the clock care for the rest of his/her life. That sort of situation deserves compensation.

I am also troubled by this idea that we can regulate our way out of the health care mess. That is a good part of the reason we're in it to begin with!

it seems like if we will end up getting paid based almost completely on performance, then one day it may happen that doctors have to "screen" their patients before they're accepted into the practice-- ie, "here's your application, patient...." they fill it out, and then if they smoke, are too fat, have an A1C over 7, or have too many CV risk factors, we'll just not accept them into the practice, else how do you keep the doors open? it seems that system would just further marginalize and stigmatize those patients that have chronic diseases, because we can't afford to take care of them... a system like that is totally not the solution

Great commentary here, you all. Again, I truly am not wanting to start any kind of flame war, but it all has been weighing heavily on my mind. I just get this awful feeling in the pit of my stomach when I hear all the political rhetoric, basically telling the population at large that they have a "right" to my brain, to my skills, and to my individual talent...for "free." (Which actually means, free for half the country, and not free for the other half, the very people that are providing it.)

This quote from Ayn Rand's Atlas Shrugged has been bandied about on several different blogs, but it really hit home with me:

"Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill?

That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun.

I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.

I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything -- except the desires of the doctors. Men considered only the "welfare" of the patients, with no thought for those who were to provide it.

That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only "to serve."

...I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind -- yet what is it that they expect to depend on, when they lie on an operating table under my hands?"

I'm not sure health care "reform" will be moving along at the speed and intensity that have been promised. Will United Health Care, whose CEO made 1.2 BILLION two years ago just say OK, lets go with a government plan?But I do see a problem in that we, as physicians, and especially as busy mothers and physicians, have had little time for political activism. We take care of our patients and our families, while multiple outside sources, whether insurance companies, trial lawyers, or mid-level personnel take over our profession. How many of us object when referred to as a "provider"; how many of us send notes or phone calls to our congressmen/senators when important bills are considered and will affect our future; it's tough to find time, but needs to be done.

I'm not sure health care "reform" will be moving along at the speed and intensity that have been promised. Will United Health Care, whose CEO made 1.2 BILLION two years ago just say OK, lets go with a government plan?But I do see a problem in that we, as physicians, and especially as busy mothers and physicians, have had little time for political activism. We take care of our patients and our families, while multiple outside sources, whether insurance companies, trial lawyers, or mid-level personnel take over our profession. How many of us object when referred to as a "provider"; how many of us send notes or phone calls to our congressmen/senators when important bills are considered and will affect our future; it's tough to find time, but needs to be done.

I agree w/ your post completely, Dr. Whoo. After spending time in the VA, I am truly scared of the idea of:1. the gov't controlling any aspect of general health care. The gov't is having trouble managing a relatively small segment of the population's health care (i.e. the vets) efficiently or appropriately. To think it could manage the entire country's is laughable.

2. the VA would give us bonuses based on patient performance outcomes (i.e. a certain percentage of patients who stopped smoking or got their flu shot). I know at least one of the physicians in our practive would regularly "fire" patients who did not meet the standards, leaving the rest of us to take care of his non-compliant patients. I see the system eventually collapsing under the sheer number of patients who cannot find a doctor willing to take care of them b/c of their illnesses.

One more thing, slightly off-topic.. one of my family members (indeed a speak-her-mind kind of person in her own right) thought it was "unprofessional" that the AMA members booed the president at times throughout his speech; she thought there should have been another more professional way for the doctors to express themselves. My immediate reaction to her comment was that it was not an unreasonable approach. What do you think?

Performance outcomes, my foot. Haven't these people ever heard of personal responsibility? Actually, the CEO of UHC made $4 billion the last year he worked there. That is why helath care reform is not needed so much as insurance reform.And it goes without saying that there will be no meaningful health care reform until there is meaningful tort reform. Fear of lawsuits is what drives a lot of the expense.

In a role of a patient I would like to comment on the perception of "performance" of the above answers.

Performance can be outcome based as well as process based. I went to good and bad doctors. A bad doctor to me is not only if he/she cannot "find" and "fix" the problem (outcome), but even more importantly if he/she does not treat me correctly (process). E.g., doctors not adequately explaining why I should take certain drugs or why certain procedures have to be done. Doctors doing procedures although they are not necessary. Doctors not doing procedures although I ask for them. Doctors treating me "from above" as if they know everything and not considering my input enough.

An example years back. I had salmonella when I was a kid, got antibiotica prescribed. Well, antibiotica isn't something I like to take because it is so hard on the body. My mother asked, well, would you give antibiotica to your kids? The doctor says 'no', that wouldn't be necessary, I could stick to a diet (and other stuff that I don't get into detail).

Another example. Doctor who did all possible procedures on my yearly woman check-up. At one time I changed my health insurance who would not pay for all the procedures and he immediately stopped with all the other procedures. It is so clear, he did them only for the money :/. I changed the doctor, especially after he was not responsive to investigating pain I had.

So, I do believe more "performance" based could be good for the patients as well as doctors.

Why can't the patient's coverage of benefits be determined on the basis on whether or not they follow standards of care recommended to them by their doctors?

Why are the docs always taking the heat?

In my own practice, it sometimes takes years before there is enough trust and elucidation of fears before someone might see a primary care doctor or get a basic set of labs drawn.

I have a choice, I can lay down "the law" and say I will only look after the patient if they also look after themselves. Or I can think about where the patient is coming from and understand their fears and concerns better and tell them I will care for them as best as I can and promise I will tell them if I think there is an urgent critical reason for them to get a medical evaluation as well.

Which do you think works better?

I have had people start to see an internist 5-7 years after they have been in treatment with me. Sometimes it is only once they go that they can verbalize what had kept them form going.

So how do we align with our patients and keep them in the medical system and not punish people for having fears?

I, with my hospital's support have started a practice involving primarily outreach to those who previously had none.

I'm removing uteruses that are literally touching the diaphragm. Doing paps on women who haven't had paps in 20+ years. Trying to find someone who will take a 30 weeker to detox from heroin. Compliance is a real issue in my practice - not surprising. Currently, I'm beating my head because my HIV positive pregnant woman takes her meds irregularly. I've had a patient no-show for her scheduled c-section!

We have started educational classes. No one shows. Social workers are very busy on the phone, ensuring that people will do the bare minimum. There is a real frustration factor involved.

I'm not asking for praise...I'm having a blast being a DOCTOR (and happily ignoring the fiscal part of the equation). I can tell you my income would be near zero if I keep these folks. What can I do, other than document no show after no show, test refusal after test refusal?

Now my privately insured patients who followed me from my previous, cushy place (and yes, they see me at a medicaid/free clinic)? They get their paps, mamms, labs, BMDs, colonoscopies on a regular basis. I would look good there.

But I'm actively discouraging my kids from this profession. To do it right takes too much effort...and you cannot do this wrong.

To Anonymous Patient -Agree with you that performance ought to be rewarded. However, the core of reform is mainly about money. And money is rarely gained by the performance measures. Some performance measures are easy to quantitate and HMO's actually did that about 10-15 years ago. Check that all patients get a tetanus shot every 10 years? Check that the female patient had her age appropriate interval of PAP and mammograms? Check that patients were treated with respect as determined by a survey? Easy to implement, no saving. So -outcomes are the next parameter to measure, and that's why we in medicine have objections to that over which we cannot control.

As someone who is not a doctor and who, after 12 years of debilitating symptoms has been diagnosed with a tumor that is affecting my endocrine system, touting "patient responsibility" seems akin to blaming the victim. I took responsibility and sought medical assistance MANY times - both traditional and non traditional.

Eventually I experienced anxiety and some depression - the prime of my life was passing me by - and all other symptoms were lumped into a generic anxiety/depression even though they predated the latter.

As I had no authority to requisition tests or medication, my scope of influence was extremely limited. At last I found a doctor who isn't giving me a speech about "pulling up my socks" or "relaxing", who tested a broader range of hormones, and who accepted that test results that are barely within "normal range" doesn't mean that they symptoms should be dismissed or downplayed.

Though it wasn't the case for me, some obese people may have actual physical issues making exercise and weight loss near. Maybe you aren't asking the right diagnostic questions (because you've prejudged obese people)? Perhaps your advice, especially if you are recommending the standard food pyramid approach to eating, is part of the problem?

Take an honest look in the mirror: do you look like someone who is a model good health?

To Bus Driver and Anonymous: I feel you are actually agreeing w/ what we are saying. Most doctors I know disagree w/ the concept of being paid based on performance outcomes (one of the things Medicare and Medicaid are arguing FOR), because, as you have pointed out, too many patients do not fit into the standard bell curve. These patients are the ones who may eventually have difficulty finding doctors to see them under some of the proposed new rules because the doctors will not get paid to see more than a certain number of them. It takes away from the partnership that most primary care doctors seek to establish with their patients.

I wish when the "public option" is used in polling that they'd inquire about premiums as a percentage of income, co-pays, and whether the respondent cares if they can see a specialist without a referral.

I think all polls skip pesky little details like -you'll have to pay and wait- and leave people thinking that the "public option" will be free.

This train may have left the station, but I don't agree with Dr. Whoo. Until recently I worked happily in settings where I got a salary,and where my patients were seeing me based on some kind of entitlement (VA or student based). Now my patients all pay out of pocket,though I still get a salary, plus bonus. This arrangement does not drive down the cost of their care, only the direct cost of seeing me. I no longer can see the patients that I might be best for or most interested in, only those who can best pay me. Nor as far as I can see does this arrangement affect patient self care or adherence to treatment. Some VA patients were very responsible, some of my private ones are not at all. Manipulating payment for health care to try to change patients' habits doesn't hold much promise. To deny insurance coverage for services like preventive care will not make patients more responsible,only less likely to seek it.

I can see the logic of providing insurance only for catastrophic care, the risk for which is unevenly distributed in the population, allowing for some degree of profit making by the insurers if they guess risks correctly (though this doesn't help providers at all). However, such a system needs to also include some prepaid health care that is not based on risk but on the fact that everyone needs medical care at various times in life, and populations need health care to protect individuals. Access to health care may not be a right but it is a fundamental need.

Taking this a step farther, if we had a catastrophic coverage only system, with no insurance for routine, preventive or elective care, would pregancy be covered? Or should it be floated in the marketplace and let the costs come down as they may? Maybe we would have fewer unnecessary c sections, but we would also have higher maternal mortality and probably more dead babies.

I am uneasy about the current debate to the extent that it lumps insurers with providers on the cost side of the ledger, and also because it conflates individual doctors with hospitals as cost drivers. But I do hear sincere efforts to addrss the fact that market forces, distorted by insurance or not, do not create rational health care systems. We don't have one, we need one, and if we ever do I will be glad to work it in, even if it means I am not as autonomous as I might like to be.

I stumbled on to your blog and after reading a hand full of posts-I am hooked!

I am a SAHM to 3 children 5, 3, and 1. I am in the docs office for checkups and all that fun stuff on a regular basis. I have watched my family docs' crazy schedules over the years-and always wonder how they have time and energy (and money) to raise their families. I am always respectful of their time and arrive on time or call if I am running 5 min. late to see about rescheduling. I try to have a small list for the 15 min appt of things I want to ask. I have been very fortunate in finding docs that explain and give background info--I love all the info!

My husband works at the university so we have very good insurance for which we are very thankful. It is still expensive but they do offer some neat preventative options that are free to us--AND we were able to pick a PPO option-a little more expensive.

Here is my point:

I agree with you, but the fundamental changes that have to occur before we can really make our system better have to do with how this country approaches their health. Medicine in the US needs to be more preventative. When I refer to patients and doctors-I am speaking in very general terms. So docs-please do not lump yourselves into these general categories...

People need to start becoming more proactive in their health--there is no pill for everything--lack of health education and personal laziness is mind-blowing in this country.

Patients need to utilize their doctor visits by going at least yearly for a check-up and asking adequate questions. Give detailed family histories when given the paperwork. Doctors need to take the time to listen and educate their patients within their alloted appt time-have resources available-handouts-websites to visit etc. When approaching patients doctors need to approach the patient as an individual and not make assumptions based off of their general clients. We are all individuals. No two people are the same. duh-right?-but you'd be amazed at how many times I have had the "Doc blew my concerns off the minute I opened my mouth" conversations with other women. Specialists tend to be the worst at this--esp. neurologists.

Docs need to learn how to ask the right questions to tease out the answers. Patients must be honest with themselves and their doctors. Doctors are only as good as the information/details the patients give them to go on. It all goes back to education at a very basic level. There needs to be a partnership nurtured between patient and doctor. I voted for Obama-but I did not vote for an adversarial relationship with my doctors-and govn run health care-VA care anyone? Not for me or my family!

Tort reform is a must-esp. for specialists like obgyns. People need to learn that doctors are not miracle workers and sometimes life is completely unfair-no amount of money will make it better--just breeds more greedy lawyers ( I know-I left law school to stay home with my first child...) I was appalled and so very jaded by all the money grubbing people I met-but very impressed with the few students I met in it to make life better for others or even those just in it for the academic challenge.

We will always need tort law to protect but it should not be a way to make life seem more fair at all costs when we know it just is not. We are losing wisdom and talent because they are all leaving for other careers. Which means less access to great care for all.

I guess we just need informed consent about life-but I bet no one would read it.

It all begins and ends with personal responsibility and no amount of government can make up for it.

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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